Record review

The nursing and medical records of the admissions were reviewed by a team of 26 trained nurses and 10 trained physicians in a two-staged structured record review process. The reviewers never reviewed in hospitals where they had ever been employed. In the first stage, a nurse screened the patient records by using 16 screening criteria indicating potential adverse events, including unplanned readmissions. In this stage of the record review, the nurse assessed whether the discharge letter was present in the patient record and the date of sending. In the second stage, one physician reviewed the patient records with one or more positive screening criteria assessed at the first stage. Based on a standardized procedure the physician determined the presence of adverse events and their preventability. An adverse event was defined as an unintended injury among hospitalized patients that results in disability, death or prolonged hospital stay, and was caused by health care management [8]. In the records with at least one positive screening criterion for an adverse event the physicians judged also the correctness of applicable components of the discharge letter if available. Physicians were considered as the experts in judging the contents of the discharge letter. Therefore, the judgement of the correctness of the discharge letter took place at stage 2. In total 4048 patient records were screened by nurses and assessed for the presence and timeliness of the discharge letter, and 2632 patient records were reviewed by physicians and judged for the correctness of the applicable components of the letter.

Data were abstracted regarding the presence and correctness of the following components of the discharge letter: name of the patient, date of birth of the patient, date of admission, date of discharge, patient history, most important outcomes of tests, most important laboratory results, information about consultations and the conclusions, conclusions / diagnosis, answers to the questions of the general practitioner / referrer, treatment and prognosis, complications, treatment after discharge, changes in medication, follow up and appointments, and name and function of the discharging physician.

As official guidelines on components of discharge letters were not available and implemented in the Netherlands, the list of components was based on existing literature and one official guideline on information exchange between physicians and family practitioners [10, 11], expert opinions and unofficial guidelines for example from individual hospitals. Physicians also collected data about the timeliness of the discharge letter. Data about the admission characteristics (length of stay, admission department, urgency) were collected from the patient records and from the hospital administrative system.